Pre-Consultation Form

Please complete the pre-consultation form prior to attending your consultation appointment.

Trinity Trichology Clinic

33, Down Way, Northolt, UB5 6PG

Phone

07956 293 093

Email

First Name

Last Name

Email

Phone

Address

Date of Birth

Sex

Male

Female

Prefer not to say

Dr/GP Name

Occupation

How long have you worked in this position?

Medical History (food, medication, known deficiencies e.g. iron, vitamin D, alergies, intolerances, thyroid) Please give details.

Have you had a blood test in the last 6 months? Please upload the results.

Upload File

Have you given birth within the last 6 months?

Yes

No

List of Medications - Including contravceptives

Are you currently receiving any medical attention? Give details if applicable.

Accidents

Illnesses

Have you had any operations in the last 3 years? Give details if applicable.

Please give a brief description of when and how your hair started thinning/shedding/breaking.

Upload a picture of the back of your hair

Upload File

Upload a picture of the front of your hair

Upload File

Upload a picture of the side of your hair

Upload File

Upload a picture of the other side of your hair

Upload File

Thank you for completing the pre-consultation form. Your answers will be reviewed prior to your appointment.

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